Provider Demographics
NPI:1306828587
Name:ST FRANCIS PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:ST FRANCIS PHYSICIAN SERVICES INC
Other - Org Name:HOLLY TREE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:864-605-3762
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-297-7091
Mailing Address - Fax:877-379-3079
Practice Address - Street 1:1338 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5637
Practice Address - Country:US
Practice Address - Phone:864-297-7091
Practice Address - Fax:877-379-3079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST FRANCIS PHYSICIAN SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-15
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8157Medicare PIN